Brachymetatarsia of the Fourth Metatarsal, Lengthening Scarf Osteotomy with Bone Graft.

Orthopedic Reviews 2013; volume 5:e21

Correspondence: Surjit Lidder, Department of
Trauma and Orthopaedics, Eastbourne District
General Hospital, Kings Drive, Eastbourne, East
Sussex BN21 2UD, UK.
Tel. +44.1323.418241 - Fax: +44.1323.414963.
E-mail: surjitlidder@me.com

Keywords: omnitech, scarf osteotomy, lengthening.

Acknowledgements: we would like to thank Dr. S.
Molki for illustrations.

Contributions: the authors contributed equally.

Conflict of interests: the authors declare no
potential conflict of interests.

Received for publication: 28 January 2013.
Revision received: 28 May 2013.
Accepted for publication: 17 June 2013.

This work is licensed under a Creative Commons
Attribution Noncommercial 3.0 License (CC BY-
NC 3.0).

©Copyright A. Desai et ai, 2013
Licensee PAGEPress, Italy
Orthopedic Reviews 2013; 5:e21
doi:10.4081/or.2013.e21

Brachymetatarsia of the fourth
metatarsal, lengthening scarf
osteotomy with bone graft

Ankit Desai, Surjit Lidder,
Andrew R. Armitage,
Samuel S. Rajaratnam,
Andrew D. Skyrme

Department of Trauma and Orthopaedics,
Eastbourne District General Hospital,
East Sussex, UK

Abstract

A 16-year-old girl presented with left fourth
metatarsal shortening causing significant psy-
chological distress. She underwent lengthen-
ing scarf osteotomy held with an Omnitech®
screw (Biotech International, France) with the
addition of two 1 cm cancellous cubes (RTI
Biologies, United States). A lengthening z-
plasty of the extensor tendons and skin were
also performed. At 6 weeks the patient was
fully weight bearing and at one-year follow up,
the patient was satisfied and discharged. A
modified technique of lengthening scarf
osteotomy is described for congenital brachy-
matatarsia. This technique allows one stage
lengthening through a single incision with
graft incorporation by 6 weeks.

Introduction

Brachymetatarsia is a congenital shortening
of the metatarsal of the foot. It can be either uni
or bilateral, 1 and is most commonly associated
with the 4 th toe but can affect any of the
metatarsal bones. 2 Patients may present due to
metatarsalgia, soft tissue contractures, 2 or psy-
chological distress during adolescence.
Operative intervention can improve function as
well as cosmesis. Lengthening may be achieved
through callotaxis using a mini-external fixator
or through a single stage procedure utilising an
osteotomy, bone grafting and soft tissue correc-
tion. 23 This case illustrates the use of a lengthen-
ing scarf osteotomy augmented with cancellous
bone graft cubes and soft tissue correction to
treat brachymetatarsia. This modified technique
provides improved metatarsal length and cosmet-
ic benefit with a single operative procedure.

Case Report

A 16-year-old female was referred with uni-
lateral shortening of the left 4 th toe. The toe

was not painful, however caused psychological
distress when wearing opened toed footwear
and whilst barefoot at swimming pools.
Examination revealed a left 4 th toe that was
clearly short and sitting dorsally. Radiographs
(Figure 1) showed a 4 th metatarsal which was
approximately 7 mm shorter that the 5 th
metatarsal with a dysplastic metatarsal head.
The etiology of her deformity was unknown.

A single stage lengthening metatarsal scarf
osteotomy was performed. The rationale for a
single procedure was to limit disruption from
schooling. The 4 th metatarsal was approached
through a laterally based Z-plasty incision. A
wide capsular release was performed and the
metatarsal was elevated up and a lengthening
scarf osteotomy performed. Two 1cm allograft
cancellous cubes (RTI Biologies, United
States) were used and the osteotomy held with
one Omnitech® screw (Biotech International,
France) (Figure 2). Z lengthening of the short
and long extensor tendons was performed.

Post operatively, the patient remained heel-
weight bearing for 6 weeks. The patient had
routine post-operative follow up (Figure 3) and
the additional length of 9 mm (2 mm longer
than 5 th metatarsal) had been maintained,
however, there was some scar contracture
keeping the toe dorsally elevated by ten
degrees. The patient remained satisfied with
her overall increase in length of the 4 th toe and
was discharged at one year.

Discussion

The forefoot deformity known as
brachymetatasia is a malformation of any of
the metatarsals. It most often effects the 4 th toe
and may be either uni or bilateral. 4 The inci-
dence of this rare deformity is reported
between 0.02 to 0.05% and is up to twenty five
times more prevalent in women compared to
men. 2 Although the main proportion of congen-
ital brachymetatasia is idiopathic in nature it
can also be associated with endocrinopathies,
such as pseudo-hypoparathyroidism, as well as
systemic syndromes such as Turner's syn-
drome. 45 The underlying cause of this short-
ened metatarsal is thought to be due to the
premature closure of the metatarsal epiphy-
seal growth plate, however, the aetiology
behind this is not fully understood. 2 5 There are
a number of other acquired causes for the
development of shortened metatarsals.
Principally trauma and infection, however
tumours, radiation exposure and previous sur-
gery are also associated. 5 Morton's foot, a short
first metatarsal, is another less common form
of brachymetatasia that becomes obvious by
the age of 10 years old.

Patients with brachymetatasia may present
in a number of ways. The short toe may sit dor-

sally which affects cosmesis and impairs load
transference of the foot. 16 This can lead to
metatarsalgia and callosities particularly over
the second and third metatarsal heads. 2 6 With
soft tissue imbalance, clawing of the toe may
be problematic for shoe wearing. 4

The aim of surgery in these cases is to pro-
vide symptomatic relief and cosmesis. The two
main methods of surgical correction are of dis-
traction osteotomy providing a gradual
increase in length, and the single stage
osteotomy with bone graft to produce a rapid
lengthening (Table 1).

Our case presents a modified surgical tech-
nique using a scarf osteotomy with a fixating
Omnitech® screw, alongside a tendon Z-plasty
of the short and long extensor tendons to pro-
duce desirable results. By using a scarf
osteotomy rather than a transverse, we allow
for controlled elongation of the metatarsal with
secured fixation. This decreases the chance of
metatarsal shortening post operatively, which
can be seen with the transverse osteotomy. It
also removes the need for a holding Kirscher
wire which is often inserted and removed at a
later date once the transverse osteotomy has
begun to heal. The cancellous bone blocks
were held in place by compression pres fit.
When the scarf osteotomy is performed, dis-
traction at the site causes surround soft tissue
compression and maintains a press fit for the
bone blocks.

The management of brachymetatarsia can be
complicated and it is particularly important to

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Case Report

Table 1. The two most common methods used for the management of brachymetatarsia.

Method

Surgical technique

Advantages

Disadvantages

References

Distraction osteogenesis
with mini-external fixation

Application of mini-external
fixator after a transverse
osteotomy. Up to 12 days
of gradual increasing of length

Longer lengthening
possible

Significant scarring, skin tension
from four fixator pin sites,
patient co-operation, pin site
infections, requires second
nrftfpdnrp to rpmnvp riklraptinn
device

Takakura^fl/,1997,

(7 patients, Follow up 4.4 years)

Magnan etai, 1995

(7 patients, mean

follow lin fi S vparO

Single stage with allograft
bone graft

Tendon Z-Plasty
Transverse osteotomy
with bone block between held
in place by k-wire

Single main procedure, tendon
z-plasty, smaller scar

K-wire requires removing,

limited lengthening due

to soft tissue tension,

post-procedure reduction in lengthening,

autologous donor site morbidity

Giannini^fl/,2010
(29 patients, mean
follow up 5 years)

Figure 1. AP radiograph of the left foot
showing 7 mm shortening of the 4 th
metatarsal compared to the 5 th metatarsal
head.

Figure 3. Post-operative AP radiograph at 6
weeks of the left foot showing the length-
ening scarf osteotomy? incorporation of the
bone blocks and fixation with an
Omnitech screw® of the 4 th metatarsal. The
4 th metatarsal head is 2 mm longer than the
5 th metatarsal head.

Figure 2. Diagram showing lengthening scarf osteotomy of the metatarsal (A) with bone
grafts and Omnitech® screw fixation (B).

consider that young women, the main patient
group, desire a cosmetic improvement due to
the already high levels of psychological distress.
This was true in our case where it was felt that
a single-stage operation would be the most
appropriate method and would be the least
restricting on her daily life. The scarf osteotomy
augmented with bone graft cubes should
decrease the risk of the patient requiring a sec-
ond operation and early results have so far
shown this. This case indicates the importance
of patient selection when considering which
operative procedure to undertake and to consid-
er the long-term impact of the operation.

A lengthening scarf osteotomy with screw
fixation and the use of cancellous bone blocks
is a modified technique for the surgical man-
agement of brachymetatasia that provides a
good alternative to traditional techniques.

References

1. Rozburch S, Ilizarov S. Limb lengthening
and reconstruction surgery. London:
Informa Healthcare; 2006.

2. Giannini S, Faldini C, Pagkrati S, et al.
One-stage metatarsal lengthening by allo-
graft interposition: a novel approach for
congenital brachymetatarsia. Clin Orthop
Relat Res 2010;468:1933-42.

3. Guizar-Cuevas S, Mora-Rfos FG, Mejfa-
Rohenes LC, et al. [Elongation with cal-
lotaxis for congenital brachymetatarsia].
Acta Ortop Mex 2010;24:395-9. [Article in
Spanish].

4. Magnan B, Bragantini A, Regis D,
Bartolozzi P. Metatarsal lengthening by
callotasis during the growth phase. J Bone
Joint Surg Br 1995;77:602-7.

5. Scuderi G, Tria A. Minimally invasive sur-
gery in orthopaedics. New York: Springer
Publications; 2009.

6. Takakura Y, Tanaka Y, Fujii T, Tamai S.
Lengthening of short great toes by callus
distraction. J Bone Joint Surg Br 1997;
79:955-8.

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